Last Days of Life Toolkit
Last Days of Life Toolkit
Bereavement Survey
Please accept our most heartfelt sympathies for your loss. Our thoughts are with you and your family during this difficult time.
Completing the Survey
Our goal is to ensure that everyone nearing the end of their life is treated with dignity and respect and receives compassionate care in accordance with their wishes in the place that they choose. We are also committed to involving and supporting families and carers during this time.
To be sure we achieve that goal could you please take the time to complete this survey on behalf of / with your family. Your experience will help us to see the quality of care we provide and continue to work toward improvement.
Thank you
Hospital: ______
Ward: ______
Please tick your responses as Yes or No
1.During the last admission to hospital were you given the opportunity to talk with any of the doctors involved in your relatives/friends care?
__Yes
__No
2.If you spoke to a doctor, did you understand what the doctor was explaining to you about what was happening, or what was expected to happen?
__Yes
__No
Comment:______
3.Whilst your relative/friend was in hospital was the possibility that they may not recover or was nearing the end of their life ever discussed with them or you?
__Yes
__No
4.Was there ever a discussion that your relative/friend had a choice in where they could be cared for?
__Yes
__No
5.Did your relative/friend wish to be cared for in hospital?
__Yes
__No
If no, where was their preferred place of care?
______
6.Did you feel that the ward/room where your relative/friend was cared for was appropriate?
__Yes
__No
7.Did you feel that your relative/friend was involved in decision about his/her care (where able)?
__Yes
__No
8.Did you feel that you were involved in decisions about his/her care?
__Yes
__No
9.Were you given the opportunity to spend time with your relative/friend after they had died?
__Yes
__No
10.Did you feel that you were supported in dealing with your feelings surrounding the death of your relative/friend?
__Yes
__No
Comment:______
11.Were you informed of the support the chaplaincy team could offer?
__Yes
__No
12.Did you feel able to talk about your experiences with those involved with the death of your relative/friend?
__Yes
__No
13.Since your relative/friend died, have you been able to talk about your feelings regarding their death?
__Yes
__No
if no, is this because you did not wish to contact anyone
__Yes
__No
OR
No information was given as to who you cold contact
__Yes
__No
Comment:______
14.Do you feel that their personal wishes were respected by those who were caring for them?
__Yes
__No
Comment:______
15.Do you believe that their religious/spiritual/cultural beliefs were respected?
__Yes
__No
Comment:______
16.Do you have any comments regarding the staff who were involved in your relatives/friends care?
Comment:______
17.Do you have any further comments about the experience of your relative/friend or yourself and / or on how we can improve end of life care or bereavement services withinxxxx hospital?
Comment:______
18.Overall, and taking all services into account, how would you rate your relative/friends care in the last three months of life?
__Outstanding
__Excellent
__Good
__Fair
__Poor
Some contacts that may be helpful:
